Provider Demographics
NPI:1154592954
Name:ANDERSON, HAROLD M (MFT)
Entity type:Individual
Prefix:MR
First Name:HAROLD
Middle Name:M
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12818 HEACOCK ST
Mailing Address - Street 2:C-6
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92553-3173
Mailing Address - Country:US
Mailing Address - Phone:951-247-6542
Mailing Address - Fax:
Practice Address - Street 1:12818 HEACOCK ST
Practice Address - Street 2:C-6
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-3173
Practice Address - Country:US
Practice Address - Phone:951-247-6542
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-19
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106H00000X
CAMFC45039106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist